New York City Innocence Lost

There is no normalcy in New York City in April 2020…especially if you work in health care. What were previously evenings spent with family and friends are now lost to social distancing from those we love, engrossed in zoom meetings focused on redeployment, and realizing in our heart-of-hearts that the hardest moments have not yet come to pass. There is shockingly little demand in the city for traditional subspecialties outside of critical care, but despite the massive mobilization, we remain critically understaffed to care for the deluge of victims hit hardest by coronavirus disease 2019 (COVID-19). Traditional departments and specialty duties have largely been cast aside to work instead as collective “COVID providers.” Regardless of training, house staff and attending physicians, nurses, and technicians are all being drafted to intensive care units (ICUs), emergency rooms, and hospital wards caring for acute respiratory distress syndrome and respiratory failure. The possibility of returning to normalcy in the near future remains unfathomable.

Yet our words are not written in despair, but rather in hope that our colleagues across the country facing their own challenges will succeed and learn from our experience. As frontline healthcare providers living through this pandemic, we hope to share a few thoughts with you from a unified attending and trainee perspective. It has taken a herculean effort by our institution to double ICU and mechanical ventilation capacity within a few weeks—with ongoing plans to double even that. This has required the iron will of leadership coupled with the literal sweat and tears of health care professionals with “boots on the ground.” As an example, one ICU opened within our operating rooms that filled to a capacity of nearly 50 intubated patients in a span of 5 days. Throughout the city, cardiologists have heeded the call to service. There are not enough pulmonary, critical care, and ICU boarded-certified physicians to do this alone. When it comes to caring for critically ill patients, a cardiologist’s skillset is best adaptable. In our cardiology division, we are proud of our attendings and fellows. Their willingness to expand care outside of their comfort zone, their composure, and their compassion have been outstanding. Through this, we have witnessed camaraderie to an unwavering degree, faced uncertainty, and experienced a gamut of emotions, including fear for the health of our families and ourselves unfortunately in conflict with our calling to serve our community and patients.

As a first rule in this pandemic, we cannot emphasize how crucial honest and regular communication is. Morning video updates from hospital leadership on the evolving landscape of COVID-19 and daily emails from our frontline clinicians detailing specific numbers of COVID-positive patients and policy changes in clinical care are a must to keep everyone informed. Institution-wide multidisciplinary tele-meetings every evening, where we develop policies to streamline acute respiratory distress syndrome ventilator management and clinical protocols (eg, anticoagulation and sedation strategies), have helped create consistency in care. Dedicated conferences featuring institutional COVID-19 research and expertise in addition to broadcast meetings featuring international frontline physicians have provided a broader perspective to help “flatten the curve.” Clear communication channels must extend to our allied health professionals who bear the brunt of personal risk in this pandemic. All COVID-protocols must be created collectively with our nurses, first responders, and technicians to mitigate risk for all members of the health care team.

Unfortunately, we have also witnessed communication flaws, especially when it pertains to personal protective equipment, testing of healthcare workers, and policies to enforce quarantine and social distancing—not worthy of our status as the wealthiest nation in the world. The inconsistent and ever-changing Centers for Disease Control and local directives on surgical masks, N95 respirators, and gowning have been driven by supply rather than evidence. It is demoralizing to hear stories of providers being censured or fired because they wore masks outside of the hospital or if they voiced disagreement with inadequate personal protective equipment directives for their staff. Pictures of health care workers in the Chinese epicenter of Wuhan wearing HAZMAT suits accentuate stark differences in protections available to providers in the United States. Based on the potential for airborne exposure, we must enforce N95 respirators for all providers caring for COVID-19 patients, whether or not an aerosolization procedure is performed.^1,2 Four months into the global experience, it is unacceptable to still have mask limitations in the United States.

In addition, we must start testing all healthcare workers and enforce home quarantine for at least 14 days if positive to prevent shedding and hospital spread.³ Too many of our medical colleagues have fallen ill during this struggle. Confirmed viral polymerase chain reaction testing for those ill at home or antibody evidence of seroconversion for the asymptomatic may not give you carte blanche for carelessness but it can inspire confidence for providers and patients alike. Lastly, to the states who have not yet followed suit, we implore you to issue stay-at-home directives for your population. As painful as they may be, social distancing initiatives should continue for several more months. The virus does not distinguish between political allegiances, and at present, the good of the many measured in lives saved outweighs a temporary loss of the individual liberty to roam free.

We beseech those with expertise in medical ethics and palliative care to find your voice in this fight. Despite the growth of our ICU capacity, the fear of ventilator shortage looms heavily. With this, rationing may become inevitable. This burden of deciding who should not receive mechanical ventilation is too formidable for individual providers to bear but needs to be led by clear ethical directives and institutionally designated officers. Our ideals in medicine have always focused on the interplay between 4 equally important pillars: beneficence (doing well for our patients), nonmaleficence (doing no harm), justice (fairness of resource allocation), and autonomy (patient choice). Over the past half-century, the principle of autonomy has often trumped medical decision-making and considerations of social justice. In a not-so-theoretical construct, imagine an 80-year-old male with metastatic cancer, averbal from previous stroke, and an out-of-hospital “Do Not Resuscitate” order presenting with COVID-19 pneumonia. Out of love, the family demands intubation and reversal of code status. Let us be frank, examples like this happen on a weekly basis in hospitals, and in most places in the United States, this patient would be intubated. When resources are not scarce, the arguments are different. In the COVID-19 pandemic where we may soon run out of ventilators and providers, we would argue that the ideal of social justice must be considered. There should be both legal and hospital protections to help physicians make such distressing choices during this time.

Finally, we call out to all cardiologists to do their part in this national emergency. Although no one would ever choose to live through a pandemic, we did choose medicine and everything that the ideal entails from the time of Hippocrates to the present-day Code of Medical Ethics adopted by the American Medical Association. When you get past the societal trappings of being a doctor, it is a profession rooted in service and compassion. In our division, we have stuck to a rule that no trainee will tread on territory where a cardiology attending does not go, and to our fellows, this has provided a great source of comfort.⁴ We need to protect each other as we provide care. The cardiology community must engage in what can only be referred to as a “medical war.” After all, our mission is to understand this disease process in a short period of time, respond to the thousands in need, attempt to reunite patients with their families, learn from our mistakes, and plan for the future so that we are never again caught unprepared for such a medical emergency.

Disclosures

None.